Sir,
Candidemia is a significant cause of mortality and morbidity in neonates admitted in the neonatal intensive care units (NICUs). [1] Systemic candidiasis in neonates is increasing in frequency, especially because the survival of babies with low-birth weight has increased. Candida species are the most common fungal pathogen isolated from the blood culture of neonates. A number of risk factors are associated with the development of neonatal systemic candidiasis, such as low-birth weight babies, prematurity, prolonged antibiotic therapy, parentral nutrition and artificial ventilation. [2] Respiratory insufficiency, apnea, bradycardia, temperature instability, feeding intolerance and abdominal distension are the various clinical manifestations associated with candidiasis. [2],[3] Prompt treatment with antifungals is required in these babies. Limited data regarding the pattern of neonatal candidemia from this part of the country prompted us to undertake the present study to assess the changing trend of neonatal candidemia from Meerut city and to correlate the various risk factors and clinical presentations associated with it in our setting.
A total of 527 blood samples of clinically diagnosed septicemic neonates was collected over a period of 1 year from the NICU of Subharti Medical College, Meerut. The blood sample inoculated in the BacT/ALERT 3D pediatric culture bottle was incubated in an automated microbial detection system (bioMerieux) for up to 5 days at 37 o C. Any growth indicated was subcultured on sheep blood agar, MacConkey agar plates and Sabouraud dextrose agar slant with antibiotics but without cycloheximide (Hi-Media Pvt. Ltd., Mumbai, India). Candida species isolated were identified as per standard mycological techniques. [4]
A total of 365/527 (69.3%) cases were blood culture positive. Pure growth of Candida species was isolated from 110/365 (30.1%) cases. Pure growth of bacteria and mixed growth of bacteria and yeast were isolated from 196/365 (53.7%) and 59/365 (16.2%) of the cases, respectively. Candidaemia was defined as the presence of at least one positive blood culture containing pure growth of Candida species with supportive clinical features.
Because of advances in medical and surgical management, an increase in nosocomial fungal infection rate has been observed. In the present study, we report candidemia in 30.1% cases of neonatal septicemia. The finding is comparable to the frequency reported by other workers. [1],[2]
As per the initial reports, most cases of neonatal candidemia were caused by Candida albicans. However, recent studies from different regions of India have shown changing trends of neonatal candidemia, with emergence of non-albicans Candida (NAC) species as an important cause of neonatal septicemia. The present study also emphasizes the changing trends of Candida species, with predominance of NAC (86.4%) in cases of neonatal septicemia from Meerut city. Our result is comparable with a previous study carried out by Agarwal et al., [5] where NAC was isolated in 84.4% cases from Lucknow, another city in Uttar Pradesh. Similarly, increasing rates of NAC have been reported by various workers from different regions of India. [1],[2],[6]
Candida glabrata (39%) was the predominant NAC species isolated in our setting, followed by C. tropicalis (26.4%), C. parapsilosis (14.5%), C. guilliermondii (2.7%), C. krusei (1.8%), C. dubliniensis (0.9%) and C. lusitaniae (0.9%) [Table 1]. NAC species, especially C. tropicalis, C. krusei, C. glabrata and C. parapsilosis, tend to be less-susceptible to azoles, particularly fluconazole, than C. albicans. C. krusei is innately resistant to fluconazole. Studies have also revealed an inherent fluconazole resistance in C. glabrata thus emphasizing the need to identify Candida up to the species level, especially in the high-risk population.
 | Table 1: Distribution of various Candida species isolated from blood in cases of neonatal candidemia (n=110) Click here to view |
We retrospectively correlated our results of candidaemia with the clinical presentation of the neonates and associated risk factors. It was observed in the present study that respiratory distress (74.55%) (P<0.01) was the most common clinical presentation, followed by failure to thrive (70%) (P<0.01), lethargy (64.55%) (P<0.01) and feed intolerance (60.91%) (P<0.05) [Table 2]. Bleeding tendency (57.27%) and convulsions (43.64%) were the less-common clinical features (P > 0.05) seen in our cases. Similar findings have been reported in the past. [2],[3] Low-birth weight was the most common risk factor (79.09%) (P<0.01) seen in our cases, followed by prematurity (67.27%) (P<0.01). Prolonged intravenous antibiotics (49.09%) (P>0.05), ventilatory support (47.27%) (P>0.05), prolonged hyperalimentation (30%), corticosteroid therapy (13.64%) and prolonged central venous line (10.91%) were less-common risk factors observed (P<0.01) in our study.
 | Table 2: Various clinical presentations observed in cases of neonatal candidemia (n=110) Click here to view |
To conclude, the present study emphasizes the mycological shift of Candida species in neonatal candidemia with predominance of NAC species from Meerut city, definitely a changing trend (P<0.01) [Table 3]. Thus, reporting of fungal blood stream infection and the spectrum of species involved are essential measures in any intensive care unit in order to implement appropriate preventive and therapeutic strategies. As various risk factors for neonatal candidaemia in a high-risk population have been identified, our study further emphasizes that appropriate measures must be taken to reduce the risk factors wherever possible.
 | Table 3: Potential risk factors identified in cases of neonatal candidemia (n=110) Click here to view |
 References |  |
| 1. | Rani R, Mohapatra NP, Mehta G, Randhawa VS. Changing trends of Candida species in neonatal septicemia in a tertiary North Indian hospital. Ind J Med Microbiol 2002;20:42-4.  |
| 2. | Narain S, Shastri JS, Mathur M, Mehta PR. Neonatal systemic Candidiasis in a tertiary care centre. Ind J Med Microbiol 2003;21:56-8. |
| 3. | Ariff S, Saleem AF, Soofi SB, Sajjad R. Clinical spectrum and outcomes of neonatal candidiasis in a tertiary care hospital in Karachi, Pakistan. J Inf Dev Ctries 2011;5:216-23. |
| 4. | Moore GS, Jaciow DM. Mycology for the Clinical Laboratory. Reston, Virginia: Reston Publishing Company Inc.; 1979. p. 323. |
| 5. | Agarwal J, Bansal S, Malik GK, Jain A. Trends in neonatal septicemia: Emergence of non-albicans Candida. Indian Pediatr 2004;41:712-5. |
| 6. | Chakrabarti A, Singh K, Das S. Changing face of nosocomial candidemia. Ind J Med Microbiol 1999;17:160-6. |
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